Transcript Infant Milk Formula Update - Southern Health NHS Foundation Trust

Infant Milk Formula Update: What,
when and why?
Sally-Ann Denton
Chief Community and Paediatric Dietitian
Portsmouth Hospitals NHS Trust
September 2010
Overview
• Standard formulas
– Main differences
– When to use
– considerations
• Specialised formulas
– Indications & contraindications for use
QUIZ
Standard Formulas
• Breast milk best (WHO)
• Infant formulas based on modified cows milk with
additions to bring as close to breast milk as possible.
• First milks whey dominant (as is breast milk)
• Often labelled number ‘1’
• Casein dominant milks sometimes called second milks
(numbered as ‘2’ ) Marketed for hungrier baby– no
evidence that will satisfy baby better /delay weaning
• NB SMA hungrier baby milk no number
Standard Milk Formulas
Recent Advances
• Always aiming to be
closer to breast milk :
additions to mimic
beneficial effects
• Prebiotics added to
some formulas – can help
with immunity (promote
colonisation of the GI
tract by probiotics),
prevent GI infections and
diarrhoea, soften stools
and may prevent atopic
dermatitis
• Nucleotides – involved in
cellular immunity
important in tissues with
rapid turnover e.g. GI
tract & immune system in
infants
• LCPs – help with brain &
eye development source often fish oils
• Antioxidants – e.g. beta
carotene and selenium
• Protein – SMA First
Infant Milk (and some
others) contain 1.3
g/100ml cf 1.4g/100ml
• Others 1.3-1.4g/100ml
• Extra hungry milks
1.6g/100ml
• Lower levels of protein in
formula may slow infants
weight gain so that it is
closer to that of breast
fed babies and reduce
risk of later obesity
• SMA ↑ α –lactalbumin
and ↓β- lactoglobulin
Organic Milks
• Don’t always contain additions e.g. Hipp
Organic - no nucleotides added
• Organic ≠ vegetarian
Follow On Formulas
• Suitable from 6 months onwards
• Compared to cow’s milk: less protein ,higher Fe and Vit C
• Compared to first milks : higher Fe & Zn therefore MUST
NOT BE GIVEN if baby < 6 months
• Some higher protein content
• N.B SMA Follow on now labelled as 2 – can be confusing
• Not necessary but can be helpful for older infants and
toddlers if diet poor
Toddler Milks
• From 1 year upwards
• Not usually necessary but can be helpful
for toddlers with poor diets
• Often display number ‘4’ – but SMA
Toddler milk = ‘3’
• NB cost may be an issue
Goodnight Follow On Milks
Aptamil Comfort
• For minor GI problems – not prescribable
• Contains partially hydrolysed whey
protein, prebiotics ,modified fat and
thickeners
• Manufacturers suggest may help colic/
minor digestive problems but evidence
weak
Specialist Milks
• Different composition to standard milks:
– Protein - whole – but ? different source
- extensively hydrolysed
- elemental (amino acids)
– Fat
- LCT
- MCT
– Carbohydrate - lactose
- glucose
– Viscosity
Pre thickened formulas
• Enfamil AR and SMA Stay down
• Available OTC and prescribable for G.O.R.
• Contain starches that thicken in the stomach
• Normal consistency in bottle but thickens upon
contact with stomach acid
• Contain whole milk protein and lactose and are
therefore unsuitable for treating CMPI
Lactose Intolerance
• Usually secondary and therefore transient (post-infective
e.g. to rotavirus)
• Treat with lactose free formula: e.g. Enfamil O-Lac or
SMA LF plus a milk free diet
• Usually recovers 2 to 4 weeks after infection
• Primary, congenital lactase deficiency very rare.
• Some patients from East and South-East Asia and Africa
may suffer from primary hypolactasia (typically age
3yrs+)
• Still contain casein and whey proteins - NOT SUITABLE
FOR COWS MILK ALLERGY
• Infants> 1 year of age can use whole milk
supermarket lacto free milk – cheaper
• Lactase drops to add to formula/ breast
milk also an option for transient lactose
intolerance
Cow’s Milk Protein Hypersensitivity
• Describes IgE mediated allergy and non-IgE
mediated allergy (intolerance)
• Manifests itself through variety of symptoms,
mild to severe including anaphylaxis,
urticaria, GOR, FTT, diarrhoea, constipation,
severe atopic eczema
• Treatment: appropriate formula and milk free
solids
• N.B: babies with hypersensitivity to cow’s milk
protein may still be thriving on presentation
Cow’s Milk Protein Allergy
• Babies < 6 months: use extensively hydrolysed formula
(EHF) e.g. Nutramigen1, Pregestimil, Pepti junior (whey
based +MCT oil), Aptamil Pepti ( whey based +lactose)
•
Soya formula not recommended as first line treatment :
– high phytoestrogen content
– potential risk to long term reproductive health (from
animal studies)
– Except in Galactosaemia
• > 6 months: soya formula safe (lower dose of
phytoestrogens per kg body weight)
• Or use extensively hydrolysed formula e.g. Nutramigen 2
Amino Acid Based Formulas
• Based on artificial amino acid mix
• e.g. Neocate LCP Nutramigen AA
• Use if:
– anaphylaxis / breathing difficulties with whole protein
formula
– growth failure
– No improvement in breast fed infant with mother on
milk free diet
– blood in stools
– no clinical response with hydrolysed formula (to which
90% babies respond to)
– refusal of hydrolysed formula
Use Of EHF and Amino Acid Formulas
• Prescribe for as long as needed.
• Dietetic supervision important to ensure
nutritional adequacy of diet – refer early
• Calcium and Vitamins needed if formula intake
inadequate
• Don’t normally challenge before 1 year of age
• 50% infants outgrow cows milk protein
hypersensititvity by 1 year and 80% by age 2-3
Cows Milk Allergy in Breastfed Infants
• In breast-fed babies:
– Place mum on a strict milk free diet (avoiding
obvious dairy and traces of dairy products)
– Ensure that she receives calcium
supplementation (1000mg/day eg Calcichew
b.d. or Sandocal 1000 o.d.)
Unsuitable Milks
• Goats milk / goats formula unsuitable
• Rice milk must not be given to <5’s inorganic
arsenic levels potentially harmful
• Supermarket soya milk low fat and low in
protein not nutritionally complete
• Other nut milks low in protein not nutritionally
complete
• Oat milk low energy and low protein not
nutritionally complete
High Energy Milks
• Contain whole cow’s milk
based protein and lactose
• Used in faltering growth
• Nutritionally complete
and RTF
• High protein: energy ratio
to promote catch up
growth
• Infatrini (Nutricia)
100Kcal/100ml
for 0-12 mths / up to 8kg
body weight
• SMA High Energy
91kcal /100ml for infants
up to 18 mths of age
• Similac (Abbott)
101 kcal /100ml
for 0-18 mths (8kg)
• (standard formula: 68
kcal per 100 ml)
Quiz Answers
• How did you do?